Hand & Wrist Pain self-referral form v2 (RMC friendly)

The physiotherapy and hand therapy departments are offering both remote (telephone or video) and face to face appointments

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This is a self-referral form for the ADULT musculoskeletal services at Guy's & St Thomas NHS Foundation Trust
If you are UNDER 16 years of age, we will be unable to accept your referral. As such, please DO NOT complete this form and instead make a GP appointment.

IMPORTANT: If you have recently or suddenly developed ANY of the following problems, please DO NOT complete this form and make a GP appointment or call NHS 111

Recently become unsteady on your feet or have recent unexplained falls
Have reduced dexterity (movement tasks of the hands). E.g doing and/or undoing buttons, handling coins or writing
Have pins & needles (tingling) or numbness (cannot feel the skin) in both arms
Are feeling unwell/have a fever (high temperature)
Have unexplained weight loss
Have a history of cancer in the last 5 years

To continue with the self-referral form you are required to confirm you are not affected by ANY of the above:

None on the above